Table Of ContentNon–Operating
Room Anesthesia
Mark S. Weiss, MD
Assistant Professor of Anesthesiology and Critical Care
Director of Inpatient Anesthesia Endoscopy Services
Perelman School of Medicine
Hospital of the University of Pennsylvania
Philadelphia, Pennsylvania
Lee A. Fleisher, MD
Robert D. Dripps Professor and Chair of Anesthesiology and Critical Care
Professor of Medicine
Perelman School of Medicine
Senior Fellow, Leonard Davis Institute of Health Economics
University of Pennsylvania
Philadelphia, Pennsylvania
1600 John F. Kennedy Blvd.
Ste 1800
Philadelphia, PA 19103-2899
NON–OPERATING ROOM ANESTHESIA ISBN: 978-1-4557-5415-1
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Library of Congress Cataloging-in-Publication Data
Non–operating room anesthesia / [edited by] Mark S. Weiss, Lee A. Fleisher.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4557-5415-1 (hardcover)
I. Weiss, Mark S. (Mark Steven), editor. II. Fleisher, Lee A., editor.
[DNLM: 1. Anesthesia--standards. 2. Process Assessment (Health Care)--methods. WO 200]
RD81
617.9’6--dc23
2014014682
Executive Content Strategist: William Schmitt
Content Development Specialist: Lisa Barnes
Publishing Services Manager: Jeff Patterson
Project Manager: Clay S. Broeker
Design Direction: Louis Forgione
Cover Designer: Elaine Kurie
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
This book is dedicated:
to Lee Fleisher for his trust and friendship.
to my aunt, Lillian Brick, who is my sunshine.
to my mother, Minnette Weiss, who has always been so supportive.
to my father, Frederick Weiss, who was always there to guide me.
to my sons, Isaac, Noah, and Henry David.
And this book is dedicated to the love of my life, Paulette Marie Lambert.
MSW
This book is dedicated to my wife, Renee, and my children,
Jessica and Matthew, for supporting me in my career
while ensuring that I understand what is truly important.
LAF
About the Authors
Mark S. Weiss, MD, is an Assistant Professor of Anesthe- Lee A. Fleisher, MD, is the Robert D. Dripps Professor and
siology and Critical Care at the University of Pennsylva- Chair of Anesthesiology and Critical Care and a Professor
nia’s Perelman School of Medicine. He received his medical of Medicine at the University of Pennsylvania’s Perelman
degree from the University of Cincinnati and completed School of Medicine. He received his medical degree from the
his residency training at Yale University. His focus is on State University of New York at Stony Brook, from which
perioperative management of high-risk patients, with an he received the Distinguished Alumni Award in 2011.
emphasis on non–operating room anesthesia (NORA). He is His research focuses on perioperative cardiovascular risk
currently the director of Inpatient Endoscopy Services at the assessment and reduction and the measurement of qual-
University of Pennsylvania. ity of care, and he has received numerous federal, industry,
and foundation grants related to these subjects. He is Presi-
dent of the Association of University Anesthesiologists. He
is a member of the Consensus Standards Advisory Commit-
tee of the National Quality Forum and of the Administrative
Board of the Council of Faculty and Academic Specialties of
the Association of American Medical Colleges. In 2007, he
was elected to membership of the Institute of Medicine of
the National Academy of Sciences.
v
Contributors
Rose Campise-Luther, MD, FAAP Anil Gupta, MD, FRCA, PhD
Assistant Professor Associate Professor
Pediatric Anesthesiology Department of Anesthesiology and Intensive Care
Medical College of Wisconsin Institution for Medicine and Health
Milwaukee, Wisconsin Örebro, Sweden
Thomas Cutter, MD, MAEd Manon Hache, MD
Professor Assistant Professor
Department of Anesthesia and Critical Care Department of Anesthesiology
University of Chicago Columbia University Medical Center
Chicago, Illinois New York, New York
Christina D. Diaz, MD Eric A. Harris, MD, MBA
Assistant Professor Associate Professor of Clinical Anesthesiology
Pediatric Anesthesiology Department of Anesthesiology, Perioperative Medicine,
Medical College of Wisconsin and Pain Management
Milwaukee, Wisconsin University of Miami, Miller School of Medicine
Miami, Florida
Karen B. Domino, MD, MPH
Professor Jennifer E. Hofer, MD
Department of Anesthesiology and Pain Medicine Assistant Professor
University of Washington School of Medicine Department of Anesthesia and Critical Care
Seattle, Washington University of Chicago
Chicago, Illinois
Richard E. Galgon, MD, MS
Assistant Professor E. Heidi Jerome, MD
Department of Anesthesiology Associate Professor
University of Wisconsin School of Medicine and Public Department of Anesthesiology and Pediatrics
Health Columbia University Medical Center
Madison, Wisconsin New York, New York
Esther D. Garazi, MD Max Kanevsky, MD, PhD
Department of Anesthesia Assistant Professor of Anesthesia
Perioperative and Pain Medicine Division of Cardiovascular Anesthesia
Stanford University School of Medicine Stanford University School of Medicine
Stanford, California Stanford, California
Gregory G. Ginsberg Meghan Lane-Fall, MD, MSHP
Professor of Medicine Assistant Professor of Anesthesiology and Critical Care
Director of Endoscopy Department of Anesthesiology and Critical Care
Gastroenterology Division University of Pennsylvania
Hospital of the University of Pennsylvania Philadelphia, Pennsylvania
Philadelphia, Pennsylvania
Kelly Lebak, MD
Basavana G. Goudra, MD, FRCA, FCARCSI Anesthesiologist
Assistant Professor MetroHealth Medical Center
Department of Anesthesiology and Critical Care Medicine University of Wisconsin—Madison
Hospital of the University of Pennsylvania Madison, Wisconsin
Philadelphia, Pennsylvania
Jeffrey Lee, MS, MD
Caitlin J. Guo, MD, MBA Assistant Professor
Assistant Professor Anesthesiology
Department of Anesthesia University of Wisconsin—Madison
New York University Medical Center Madison, Wisconsin
New York, New York
vii
viii Contributors
Mark A. Leibel, MD Mark C. Phillips, MD
Assistant Professor Assistant Professor and Medical Director, Advanced GI
Department of Anesthesiology Endoscopy Anesthesia
University of Wisconsin School of Medicine and Public Department of Anesthesiology
Health University of Alabama at Birmingham School of Medicine
Madison, Wisconsin Birmingham, Alabama
Larry Lindenbaum, MD Christopher D. Press, MD
Assistant Professor Department of Anesthesiology, Perioperative
Department of Anesthesiology and Critical Care Medicine and Pain Medicine
Medical College of Wisconsin Stanford University School of Medicine
Milwaukee, Wisconsin Stanford, California
Alex Macario, MD, MBA Johan Raeder, MD, PhD
Professor Professor
Department of Anesthesiology, Perioperative and Pain Faculty of Medicine
Medicine NOR Consultant
Vice-Chair for Education Department of Anaesthesiology
Program Director, Anesthesia Residency Oslo University Hospital
Stanford University School of Medicine Oslo, Norway
Stanford, California
W. Kirke Rogers, MD
Jeff E. Mandel, MD, MS Associate
Assistant Professor of Anesthesiology and Critical Care Department of Anesthesiology
Perelman School of Medicine The University of Iowa Roy J. and Lucille A. Carver College
University of Pennsylvania of Medicine
Philadelphia, Pennsylvania Iowa City, Iowa
Ramon Martin, MD, PhD Daniel Rubin, MD
Staff Anesthesiologist Assistant Professor
Department of Anesthesiology, Perioperative and Pain Department of Anesthesia and Critical Care
Medicine University of Chicago
Brigham and Women’s Hospital Chicago, Illinois
Assistant Professor
Anesthesia John P. Scott, MD
Harvard Medical School Assistant Professor
Boston, Massachusetts Department of Anesthesiology and Pediatrics
Medical College of Wisconsin
Julia I. Metzner, MD Milwaukee, Wisconsin
Associate Professor
Department of Anesthesiology and Pain Medicine Jack S. Shanewise, MD
University of Washington Professor of Anesthesiology
Seattle, Washington Columbia University Medical Center
New York, New York
Roger A. Moore, MD
Clinical Associate Professor of Anesthesiology and Critical Preet Mohinder Singh, MD
Care Assistant Professor
Chair Emeritus, Deborah Heart and Lung Center Department of Anesthesiology and Critical Care Medicine
Perelman School of Medicine Postgraduate Institute of Medical Education and Research
Hospital of the University of Pennsylvania Chandigarh, India
Philadelphia, Pennsylvania
Scott Springman, MD
Melissa L. Pant, MD Professor
Clinical Associate Anesthesiology
Department of Anesthesia and Critical Care University of Wisconsin—Madison
University of Chicago Madison, Wisconsin
Chicago, Illinois
Lena S. Sun, MD
E.M. Papper Professor of Pediatric Anesthesiology
Department of Anesthesiology and Pediatrics
Columbia University Medical Center
New York, New York
Contributors ix
BobbieJean Sweitzer, MD Sophia van Hoff, MD
Professor of Anesthesia and Critical Care Resident
Department of Anesthesiology and Critical Care Department of Anesthesiology
University of Chicago Dartmouth-Hitchcock Medical Center
Director Lebanon, New Hampshire
Anesthesia Perioperative Medicine Clinic
Professor of Medicine Lindsay L. Warner, BS
Department of Medicine Mayo Medical School
University of Chicago Mayo Clinic
Chicago, Illinois Rochester, Minnesota
Pedro P. Tanaka, MD, PhD Mary Ellen Warner, MD
Department of Anesthesiology, Perioperative and Associate Professor of Anesthesiology
Pain Medicine Mayo Clinic
Stanford University School of Medicine Rochester, Minnesota
Stanford, California
Nafisseh S. Warner, MD
Jonathan W. Tanner, MD, PhD Mayo School of Graduate Medical Education
Assistant Professor of Clinical Anesthesiology and Critical Mayo Clinic
Care Rochester, Minnesota
Department of Anesthesiology and Critical Care
Perelman School of Medicine Mark S. Weiss, MD
University of Pennsylvania Assistant Professor of Anesthesiology and Critical Care
Philadelphia, Pennsylvania Director of Inpatient Anesthesia Endoscopy Services
Perelman School of Medicine
John M. Trummel, MD MPH Hospital of the University of Pennsylvania
Assistant Professor Philadelphia, Pennsylvania
Department of Anesthesiology
Dartmouth-Hitchcock Medical Center
Lebanon, New Hampshire
Foreword
Anesthesiology has witnessed incredible advances over the outside of traditional operating room locations. At the
past 3 decades. Improved patient safety has been a driving Hospital of the University of Pennsylvania, the increase in
force for our advancements in medical technology, in the anesthetics delivered outside the operating room has grown
expansion of our pharmacological armamentarium, and in over the past decade from a minimal number of cases yearly
the development of innovative anesthetic techniques. The to a time today when over 30% of the anesthetics are given
reward for these improvements is better patient outcomes in nontraditional locations. Many anesthesia departments
and the ability to provide complex surgical interventions are unprepared psychologically and educationally to meet
to patients that would have been impossible to perform the increasing demand for out-of–operating room care.
without the anesthetic advancements. There has never There are significant manpower, economic, educational,
been a better time for anesthesiologists to take the sickest and patient safety factors that need to be explored in order
and most debilitated of patents of all ages through the most to operationalize an effective out-of–operating room care
highly invasive and stressful procedures in such a safe and plan. However, if an anesthesia department is to continue
effective manner. In the 21st century, and significantly to be viable in this changing surgical and procedural envi-
due to advances in anesthetic care, surgery has also had ronment, it is imperative that the departments and anes-
an increased focus on out-of-operating room procedures, thesia groups take a cooperative approach, rather than an
necessitating continued anesthesia innovation for the envi- obstructive attitude, in partnering with those physicians
ronment outside the operating room. Just a few decades performing the procedures.
ago, it was rare that anesthesiologists were called to provide In this book, Drs. Mark Weiss and Lee Fleisher have pro-
care outside the typical operating room setting; when doing vided an important tool to address both the challenges and
so, it was usually limited to emergent or highly unusual cir- opportunities for anesthesiologists in providing non–operat-
cumstances. Indeed, training programs primarily focused ing room anesthesia (NORA) care. As NORA continues to con-
on providing the highest quality and safest care under the sume more of the time and effort of anesthesia departments,
controlled environment of an operating room arena, where NORA training should become an integral part of anesthe-
supplies, equipment, and personnel were readily available sia residency programs. However, until anesthesiologists do
to support most medical complications. The “comfort zone” receive formal education in NORA, I believe this book will go
for nearly all anesthesiologists did not extend far past the a long way in expanding the comfort zone of anesthesiologists
sterile corridors of the operating room. to out-of–operating room locations. As minimally invasive
Once the acknowledgment is made that out-of-operating procedures rapidly increase, it is certain that the practice of
room anesthetic care has to be provided, guidelines for the anesthesia will significantly expand in nontraditional envi-
delivery of that care must be established. As previously ronments and that our services will be vital for the smooth
stated, providing anesthesia out of the operating room flow of patient care in all out-of–operating room settings.
typically falls outside the training and comfort zone of most
anesthesiologists. There are few comprehensive guidelines, Roger A. Moore, MD
protocols, or educational materials tailored to the specific Clinical Associate Professor of
needs of these types of anesthetics. Also, the environment Anesthesiology and Critical Care,
and the techniques are unfamiliar to many anesthesiolo- Hospital of the University of Pennsylvania
gists. Education and information are critical for both reduc- Past President, Society of Cardiovascular
ing physician anxiety and for standardizing the procedures Anesthesiologists
and practices for care outside the operating room. Past President, American Society
Recent reports filed with the Anesthesia Quality Institute of Anesthesiologists
indicate that many of the anesthetics today are delivered
x
Preface
The past several years have seen advances in medical tech- It is hoped that the information presented will facilitate
nology that allow physicians to treat a patient with mini- improved patient care and provide a resource for the inclu-
mally invasive procedures. With increasing frequency, sion of NORA training within residency training programs.
these procedures are being performed outside the tradi- This is, in many ways, an important part of the future of
tional operating room environment. Non–operating room anesthesia.
anesthesia (NORA) cases now comprise as many as 70% of There are many people who have worked hard to make
the cases being reported to the Anesthesia Quality Institute. this project possible. We would first like to thank the profes-
In spite of the exponential increase in NORA caseloads, very sionals at Elsevier who have been so wonderful to work with:
little attention has been paid to this subspecialty area and Lisa Barnes, William Schmitt, Clay Broeker, and the entire
even less with regard to developing guidelines, protocols, staff. We would like to thank Amy Meros, Administrative
and educational materials tailored to the specific needs of Coordinator in the department, who has been patient and
providing anesthesia in these settings. tireless in helping to bring this manuscript together. Finally,
This book is meant to serve as an educational resource we would like to thank the authors and contributors to this
in regard to issues of setup, quality control, patient care book for the many hours it takes to write a chapter.
and safety, and economic viability that are specific to
NORA. The contributing authors are all outstanding clini- Mark S. Weiss, MD
cians who have developed expertise that relates to NORA.
Lee A. Fleisher, MD
xi
